Information Collection

57.403 Outpatient Procedure - Monthly Denominators and Summary

IC 208407 under ICR 201308-0920-010 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form 57.403 57.403 Outpatient Procedure - Monthly Denominators and Summary Form
57.403 Outpatient Procedure - Monthly Denominators and Summary 57.403_OPCDenom_BLANK.DOCX Form
13. Outpatient Procedure Component.pdf 13 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.403 Outpatient Procedure - Monthly Denominators and Summary	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.403	Outpatient Procedure - Monthly Denominators and Summary	57.403_OPCDenom_BLANK.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	40,000	40,000
Annual IC Cost Burden (Dollars)	1,259,200	1,259,200

Documents for IC

Title	Document	Date Uploaded
13	13. Outpatient Procedure Component.pdf	08/22/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.